Federal Permit Application for an Annual Dealer Permit

Southeast Region Permit Family of Forms

Dealer App GSAD PRA 03DEC13 highlighted

Dealer permits

OMB: 0648-0205

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0648-0205 can be found here:

Document [pdf]

Download: pdf | pdf

0MB No. 0648-0205 Form Approval Expires: 10/31/2014

U.S. Department of Commerce, NOAA
NMFS PERMITS OFFICE, F/SER14
263 13th Avenue South
St. Petersburg, FL 33701
Toll Free 877-376-4877 (8:00 am. 4:30 p.m. ET)
727-824-5326 (8:00 a.m. 4:30 p.m. El)
sero,nmfs. noaa.gov

FEDERAL PERMIT APPLICATION FOR
AN ANNUAL DEALER PERMIT

FOR OFFICE USE ONLY
Reviewer’s Initials and Date
Permit Check or Money Order
Number and Amount

FOR OFFICE USE ONLY
Application ID

Sanctioned Case Number if
Sanctioned
SERO Dealer Number
Expiration Date(s)

SECTION 1 DEALER INFORMATION
-

Individual or Sole Proprietorship

Dealer entity is
(check one):

Partnership

Corporation

SERO Dealer Number

Other

if you already have
SERO Dealer permit(s)

I_________________

la. If the dealer isa partnership, corporation, or other business entity provide the business name, Federal Tax ID number, and date business was filed.
Name of Partnership, Corporation, or Business

Tax Identification Number (FEIN)

Date Business Formed (MM/DD/YYYY)

lb. If the dealer is an Individual or Sole Proprietorship complete the following information name, Social Security Number (SSN), and date of birth:
-

Mr/Mrs/Ms

Last Name

Tax Identification Number (SSN)

First Name

Middle Name

Date of Birth (MM/DD/YYYY)

Area Code

Suffix ir, Sr, etc.
-

Phone Number

ic. If you are operating under a different name,
what is your Doing Business As (DBA) name?

SECTION 2
Mailing Address

DEALER CONTACT INFORMATION
City

Apt #

Check box if the street address is the same as
the mailing address,

State

Zip Code

Country

Check box if this is a location where you receive product from
fishermen. More facilities may be added in section 5.

Street Address (P0 Box not acceptable)

Apt #

Area Code

Valid E-Mail Address

City

State

H
Phone Number

County/Parish

Zip Code

Country

H_____

Form Revision 12/03/2013

SECTION 3

PERMITS

Indicate which permit(s) and transaction(s) you are applying for. Find the fishery in the left column and mark the check box beside
that fishery to indicate which transaction you want.
NEW

RENEW

ED
ED
ED

Gulf of Mexico and South Atlantic Dealer (GSAD)
Atlantic Shark (SK)
(Includes the Gulf of Mexico and U.S. Caribbean)
Domestic Atlantic Swordfish (SD)
(Includes the Gulf of Mexico and U.S. Caribbean)

SECTION 4 COMPANY OFFICER and SHAREHOLDER INFORMATION
-

Complete Section 4 only if the Dealer listed in Section 1 is a Corporation, Partnership, or other business entity Skip this section if the
Dealer listed in Section 1 is an individual or sole proprietorship. Copy this page as needed to provide information on each officer or
partner associated by partnership, corporation, or other business relationship to the Dealer.
Position Held Check ALL That Apply
-

President/CEO
Mr/Mrs/Ms

Vice President

Last Name

Tax Identification Number (SSN)

Mailing Address

Secretary

Treasurer

Director/ Manager

First Name

Middle Name

Date of Birth (MM/DD/YYYY)

Area Code

Apt #

City

Shareholder

lOther

Suffix ir, Sr, etc.
-

Phone Number

State

County/Parish

Zip Code

Country

State

County/Parish

Zip Code

Country

Check box if the street address is the same as the mailing address.

Street Address (P0 Box not acceptable)

Apt #

City

Position Held Check ALL That Apply
-

President/CEO
Mr/Mrs/Ms

Vice President

Last Name

Tax Identification Number (SSN)

Mailing Address

Secretary

Treasurer

Director! Manager

First Name

Middle Name

Date of Birth (MM/DD/YYYY)

Area Code

Apt #

City

Other

Shareholder

Suffix ir, Sr, etc.
-

Phone Number

State

County/Parish

Zip Code

Country

State

County/Parish

Zip Code

Country

Check box if the Street address is the same as the mailing address.
Street Address (PC Box not acceptable)

Apt #

City

SECTION 5

RECEIVING FACILITIES

List the names and Street addresses for facilities where product is received (fish is off loaded from the fishing vessels). Please copy
this page as needed to provide information on all facilities where fish are received. If you marked in section 2 that your street
address is a receiving facility, you do not need to re-list it here.

Business Name

Phone Number

Area Code

Street Address (P0 Box not acceptable)

Apt #

City

County/Parish

State

Area Code

Business Name

Street Address (P0 Box not acceptable)

Apt #

City

State

Zip Code

County/Parish

Zip Code

H
Area Code

Business Name

L
Street Address (P0 Box not acceptable)

Apt #

l
l

City

State

Business Name

Apt #

II
l II

City

State

Apt #

City

County/Parish

Apt #

State

II
Street Address (P0 Box not acceptable)

Apt #

City

State

II
3

I
Zip Code

Country

Phone Number

County/Parish

Country

Phone Number

County/Parish

Area Code

Business Name

Country

Zip Code

I
II II

City

Zip Code

II
Area Code

Street Address (P0 Box not acceptable)

Phone Number

Business Name

Country

Phone Number

County/Parish

State

Zip Code

1
Street Address (P0 Box not acceptable)

H__

1
County/Parish

Area Code

Business Name

Country

Phone Number

Area Code

Street Address (P0 Box not acceptable)

Country

Phone Number

Area Code

Apt 1*

Country

Phone Number

County/Parish

State

Business Name

Street Address (P0 Box not acceptable)

Zip Code

Country

SECTION 6

STATE WHOLESALERS LICENSES

Complete the following and provide a copy of each state wholesalers license held by the dealer.
State Wholesaler
License Number

State
Issued By